Using a quality improvement approach to optimise antimicrobial prescribing

Transcription

1 Using a qality improvement approach to optimise antimicrobial prescribing Dr Jacqeline Sneddon, Glasgow, Scotland EAHP ACADEMY SEMINAR Antibiotic Stewardship for Beginners

2 Disclosre of Relevant Financial Relationships NO DECLARATIONS

3 Qestions abot qality improvement in antimicrobial stewardship v Qality improvement interventions reqire collection of large amonts of data v A point prevalence srvey is a type of adit v Qality indicators allow trends to be measred

4 Overview of session Antibiotic se in hospitals what are the problems Qality improvement methodology Adit and feedback Qality indicators Sharing reslts of interventions

5 Problems with antibiotic se in hospitals Unnecessary se e.g. viral infections, self-limiting infections, ncertain diagnosis Sb-optimal se Remember the 5 rights: RIGHT CHOICE RIGHT DOSE RIGHT FREQUENCY RIGHT ROUTE RIGHT DURATION

6 Measrement for improvement Measrement has traditionally been sed in research bt more recently has been sed in benchmarking and scrtiny within healthcare. Qality improvement methodology within healthcare has expanded rapidly over the past ten years bt effective data captre is a key factor in sccess. Electronic systems can captre data to provide qantitative and qalitative information for monitoring longitdinal trends and changes in practice. However manal collection of data throgh clinical adit may be reqired in many hospitals. When collecting data we need to think careflly abot or specific reasons for collecting it, as this will inform the type and qantity of data needed.

7 Types of data collection IMPROVEMENT ACCOUNTABILITY RESEARCH Prpose Understanding of Process Evalation of change To bring new knowledge into daily practice Comparison Reassrance To discover new knowledge Data Gather jst enogh data to learn and complete another cycle Large amonts of data on ongoing basis Gather as mch data as possible jst in case Dration Short period of time weeks, months Small tests of change accelerates the rate of improvement Medim long dration Longitdinal trends and historic data Can take long periods of time to obtain reslts Analysis Rn charts or statistical process control charts Leage tables/benchmarking achievement of target Traditional statistical tests

8 Choice of approach for antimicrobial stewardship Within antimicrobial stewardship programmes qalitative data is often sed to inflence antimicrobial prescribing behavior. If an rgent change in antimicrobial prescribing practice is reqired a qality improvement approach is best as this can have an impact on a small scale in a matter of days or weeks. For larger scale changes an accontability approach may be better, with adits over several wards and feedback to staff. This will take time to establish a baseline, set targets and reglar re-adit to determine if practice is changing. A research approach is sefl for generating robst data abot the impact of changes in prescribing on both process and patient otcomes.

9 Qality Improvement methodology There are several qality improvement methodologies sed in healthcare, e.g. the Model for Improvement, LEAN, Six Sigma, bt all se similar components. The Model for Improvement provides a simple, yet powerfl tool for accelerating improvement based on three fndamental qestions: What are we trying to achieve? A clear aim what, how mch, by when? How will we know that change is an improvement? Measring processes and otcomes. What ideas for changes can we identify that will reslt in an improvement? Test some ideas to see which changes may work. If yo wold like to learn more abot qality improvement methodology in healthcare the following resorces provide frther information: Institte for Healthcare Improvement The Health Fondation

10 Improvement cycles PLAN DO STUDY ACT Act Ready to implement? Try something else? Next cycle Stdy Complete data analysis Compare to predictions Smmarize Plan Objective Qestions & predictions Plan to carry ot: Who?When? How? Where? Do Carry ot plan Docment problems Begin data analysis Start with one patient and test some changes, once something works move on to try on 3 patients then 5 patients then whole ward

11 Won t measrement and QI mean more work when we are already bsy Every system is perfectly designed to get the reslts it gets. Everyone in healthcare has two jobs when they come to work; to do their work and to improve it. This is the essence of Qality Improvement (QI). Pal B Batalden

12 Adit of antimicrobial prescribing Adit is the key method of collecting qalitative data within antimicrobial stewardship programmes. Adit may be carried ot in a variety of ways depending on resorces available and objectives for collecting it. Continos adit data on all patients prescribed antibiotics. Rarely practical withot electronic data systems Point prevalence srveys snapshot adits across the whole hospital or selected wards at reglar time intervals to track trends. Prescribing indicators collection of selected data to provide information abot specific aspects of prescribing practice.

13 Point Prevalence Srvey (PPS) - definition Common definition for point prevalence is the amont of people with a particlar characteristic at a certain point in time. Determined by taking the total nmber of people with the characteristic divided by the total nmber of people in the poplation of interest. In healthcare often sed to determine prevalence of infection, particlarly healthcare associated infection as a performance metric. A Point Prevalence Srvey (PPS) of antibiotic se will measre the nmber of people taking antibiotics at a given point in time within a hospital/ward. For example 5 patients in a 20 bed srgical ward receiving antibiotics on the day of the srvey gives a prevalence of antibiotic se of 25%

14 Aim of PPS of antibiotic se Identify and monitor rates of antibiotic prescribing in hospitalised patients Identify differences between prescribing rates between hospital departments, hospitals, regions and contries Determine variation in antibiotics, dose and indication across different locations Help to identify targets for qality improvement in antibiotic prescribing Identify interventions to promote better stewardship of antibiotics to assist the fight against antimicrobial resistance Assess the effectiveness of interventions throgh repeated srveys

15 Cycle of AMS activities PPS provides qalitative INFORMATION INFORMATION CLINICIANS ENGAGEMENT & EDUCATION Feedback of PPS reslts QUALITY IMPROVEMENT PPS identifies areas for QI Clinicians = doctors, nrses and pharmacists

16 Information from PPS of antibiotic se Patterns of se of broad and narrow spectrm antibiotics Indications for antibiotic treatment of commnity acqired or hospital acqired infection or medical or srgical prophylaxis Which antibiotics are being sed for particlar infections? Are the antibiotics prescribed in line with local prescribing gidelines? What is the dration of antibiotics for srgical prophylaxis? Has a clear dration of treatment or stop date been recorded? Has the treatment been changed in light of microbiology reslts?

17 Getting started with PPS data collection Simple data collection form Patient ID Name of drg Rote Unit dose Dosage freqency Indication Complies with (local) gidance Using a simple paper form yo can easily collect data from patients on one ward on one day, collate and aggregate the data then analyse Scale p to small hospital and se Microsoft Excel for data collation and analysis

18 Preparing for a PPS what is reqired? Data collectors: to visit wards in the hospital within the srvey period. A large team can visit all wards over a relatively short space of time while with a smaller team it will take longer. Protocol and data collection forms: to specify which ward level data and patient level data to collect. Important to classify indication for antibiotic and anatomical site of presmed infection - sally via a list of codes. Staff training: focsed on completion of the data collection in a consistent manner. Important to ensre data collectors nderstand all definitions and codes. Commnication: engaging ward staff is important to explain why the srvey is being condcted. Information governance and data secrity: ensre the hospital s clinical governance committee are aware the srvey is being condcted and are reassred abot the safe handling of information.

19 Simple PPS Data presentation Total nmber of prescriptions by antibiotic (n=50) Total nmber of patients with each infection type (n= 50) Acte abdominal infection Celllitis Diverticlitis Pyelonephritis Wond infection Acte exacerbation COPD Commnity acqired pnemonia Netropenic sepsis Urinary tract infection

20 Example reslts from hospital wide PPS Recording of indication in notes Compliance with local gidelines Rote of administration Dration of srgical prophylaxis by specialty Intensive care 100% 90% 80% 70% Medicine Srgery Oral Parenteral 60% 50% 40% 30% 20% 10% More than 1 day 1 day Single dose 0% Other 0% 20% 40% 60% 80% 100% Central Nervos System Cardiac/vasclar srgery Ear, nose, throat Gastrointestinal Obstetric/qynaecology Respiratory Plastic/orthopaedic Urological

21 Larger scale PPS cations/pps-hai-antimicrobial-se-eu-acte-care-hospitals-v5-3.pdf

22 Global PPS A Global Point Prevalence Srvey of Antimicrobial Consmption and Resistance was developed in 2015 and will condct the next PPS in The core data set has been based on ECDC Eropean PPS. More information on the Global PPS is available at

23 Want to know more abot PPS? Next free on-line 2-week corse starts on 16th October

24 Beyond PPS developing qality indicators

25 Qality Indicators for prescribing DEFINITION explicitly defined measreable items giving a possible indication on the level of qality. Qality indicators allow trends to be measred over time between locations before/after interventions There are three main types of indicators strctral, process and otcome.

26 Types of Qality Indicators sed in stewardship programmes Strctral indicators measre whether governance strctres are in place for stewardship e.g. does a hospital have an Antimicrobial Team which meets reglarly, reports to senior management and has an action plan? Process indicators measre systems in place for stewardship e.g. srveillance programme for antibiotic se, programme of adits, edcation for healthcare staff. Otcome measres are sed to measre the impact of a stewardship programme and shold inclde both intended and nintended otcomes sch as redced se of restricted antibiotics (intended) and increase in resistance to recommended antibiotics (nintended). Patient otcome measres are the most sefl bt most difficlt to collect e.g. mortality rate, cre rate

27 Strctre indicators for stewardship Performance of 14 Scottish AMTs against 10 Eropean Validated Indicators 1. Formal mandate for hospital mtli-disciplinary antimicrobial management team (AMT) AMT member is a member of Drg and Therapetics Committee Bedside expert consltant advice regarding antibiotics on reqest available the same day Reglar ward ronds by members of AMT performed at least weekly 9 5. Clinical adit of prescribers compliance with local clinical gidelines by AMT Antibiotic formlary/list pdated biannally 14 Er J Clin Microbiol Infect Dis. 2013; 32: Local clinical practice gidelines for microbiologically docmented therapy pdated biannally* 8. Local clinical practice gidelines for empirical therapy pdated biannally 9. Local clinical practice gidelines for srgical prophylaxis available Prescriber edcation by personalised interactive methods (e.g. daily ward ronds) 9 * Not applicable to Scottish Practice Sorce: SAPG Srvey, Matrity of Antimicrobial Stewardship in Scotland, May 2014

28 Prescribing Qality Indicators Prescribing qality indicators in hospital sally focs on the process of prescribing an antibiotic and how this is docmented. DIAGNOSIS OF INFECTION ANTIBIOTIC PRESCRIBED PATIENT RECEIVES ANTIBIOTIC What cold be measred to determine qality of prescribing and identify which part of process needs improved?

29 Docmentation is key - standards for QIs DIAGNOSIS OF INFECTION ANTIBIOTIC PRESCRIBED PATIENT RECEIVES ANTIBIOTIC DIAGNOSIS signs and symptoms, differential diagnosis, reslts and management plan written in medical notes PRESCRIPTION choice, dose, freqency, rote and dration written on medicine chart or within e- prescribing system ADMINISTRATION confirmation of each dose being administered to the patient written on medicine chart or within e-prescribing system

30 Start Smart Then Focs to inform QIs Start_Smart_Then_Focs_FINAL.PDF

31 Adit tools to create prescribing QIs University Hospital Sothampton NHS Fondation Trst HAPPI adits (Hospital Antibiotic Prdent Prescribing Indicators) Adit standards 1. Indication / provisional diagnosis docmented on start date 2. Antibiotic choice according to gideline (or jstified off-gideline choice) 3. Appropriate dose prescribed 4. Reviewed at hors with docmented treatment plan 5. Total corse length 7 days (or jstified) Cortesy of K Hand & H Wickens, Consltant Pharmacists Anti-infectives Frther examples from the UK available via Start Smart then Focs toolkit /417041/Revised_SSTF_Tools_Annex_FINAL.pdf

32 Prescribing indicators sing a qality improvement approach AIM MEASURES CHANGES Start small focs on one ward with high prevalence of antibiotic se Freqent data collection and feedback focs on a few measres Test changes and repeat discss improvements with clinical team Example data collection Empirical Prescribing indicator Indication for Antibiotic Treatment Recorded in Y / N Y / N Y / N Y / N Y / N Notes? Antibiotic(s) Compliant with Local Prescribing Y / N Y / N Y / N Y / N Y / N Policy? All doses administered as per medicine chart? Y / N Y / N Y / N Y / N Y / N Patient 1 Patient 2 Patient 3 Patient 4 Patient 5

33 Prescribing qality indicators Scotland Measre 1. Doses administered 2. Indication docmented 3. Dration docmented 4. Compliant with policy Median (%) Medical Min Max (%) (%) Boards compliant Median (%) Srgical Min Max (%) (%) Boards compliant / / / / / / / /15 Median percentage compliance with measres at a national level and nmber of health boards reaching target 95% compliance.

34 Antimicrobial stewardship across 47 Soth African hospitals: an implementation stdy Health-care facilities with limited infectios diseases expertise can achieve sbstantial retrns throgh pharmacist-led antimicrobial stewardship programmes and by focsing on basic interventions.

35 Astralian hospital adit system

36 Using technology to make QI easy Antimicrobial Companion App. After login, the adit tool allows sbmission of adit data. After sbmission of data, the adit tool displays the nmber of sbmissions for that period within the selected ward. Reports created monthly by app administrator in each hospital

37 Qestions abot qality improvement in antimicrobial stewardship v Qality improvement interventions reqire collection of large amonts of data v A point prevalence srvey is a type of adit v Qality indicators allow trends to be measred

38 THANKS FOR LISTENING ANY QUESTIONS? Contact details: